WHAT'S UP DOC? Pelvic fracture

Tuesday

Jan 9, 2018 at 1:04 PMJan 9, 2018 at 1:04 PM

By Dr. Jeff Hersh/Daily News Correspondent

Q: My grandmother fell and broke her pelvis last year. They sent her home a couple of days later and she was able to walk and did fine. My 35 year old neighbor was in a car crash and broke his pelvis. He needed to be in the ICU for a week and required surgery. Aren’t injuries usually worse when you are older?

A: The pelvis is the cone-like ring of bones between the abdomen and the thighs that forms the bony connection between the spine and the femurs (the thigh bones). It is made up of the lower spinal bones (the sacrum and the coccyx) and the ilium, ischium and pubis (which fuse to form the acetabulum which is the socket that the ‘ball’ end of the femur sits in to make up the hip joint). The pelvis is quite strong, in large part due to the ligaments and muscles that hold all these bones together. There is a rich blood supply to the pelvis, which is the major reason why severe pelvic trauma is often associated with significant internal bleeding.

Pelvic fractures may include ring disruptions, sacral fractures, acetabulum fractures and/or avulsion fractures (when a ligament or muscle pulls away part of a bone). There are several classification protocols for the different types of pelvic fractures, but the details of those go beyond the goals of this article. As with most injuries, there is a huge range of severity in pelvic fractures, ranging from minor to life threatening. The specifics depend on the mechanism of injury, as well as the patient characteristics.

Older people often have osteoporosis (thin, fragile bones which, for example, affects over a third of all post-menopausal women), and may suffer a pelvic fracture from minimal trauma or even from repetitive stresses without a specific traumatic event. Many of these fractures are minor (such as non-displaced cracks in the anterior ring’s pubic rami or the posterior pelvis’ sacral ala) and are treated with pain control and early mobilization.

Severe pelvic fractures most often occur from high energy impact trauma, such as from a motor vehicle accident or a fall from a significant height. Some severe pelvic fractures are unstable; for example, when there are two or more fractures in the pelvic ring, the pelvis may become unstable. Severe fractures may need aggressive treatment, often including surgery using screws, plates, etc. to reconstruct the anatomical alignment of the bony structures.

The first step in caring for a patient with a suspected severe pelvic fracture is evaluation of their clinical status; for example, are they in shock (meaning they are not adequately getting blood to vital organs such as the brain, heart, kidneys, etc.) and/or do they have other injuries which may be life threatening? The next step is to immediately address any potential critical injuries and complications (for example, life threatening bleeding requiring a blood transfusion occurs in over a third of severe pelvic fractures that require hospitalization).

Once the patient is stabilized (or if they are initially stable as is usually the case in minor pelvic fractures), an X-ray is usually ordered to see if there is a fracture. If this does not give a definitive answer, or if other pelvic injuries are suspected (such as internal bleeding), a CT scan (and sometimes an angiography where special iodinated dye is used to specifically image the blood vessels to look for bleeding) may be required. Other tests (including blood tests and other imaging tests) may be needed to identify other injuries.

Pelvic fractures represent only 3 percent of all broken bones. However, a substantial percentage of pelvic fractures are life threatening (directly from the fracture or from associated injuries), with an overall mortality rate of up to one in seven patients. Bad prognostic indicators include open fractures (the broken bone protrudes through the skin), severe concomitant injuries and presenting in shock (usually indicating large amount of blood loss, most often from internal injuries which are from venous bleeding in most cases, so the patient may not be bleeding externally at all).